How the Gold Medal Puck Was Almost Lost

As an American, and a Red Wings fan, it pains me, in a way, to write about Sidney Crosby and the Canadian team's overtime victory in the gold medal game. I'm currently in Edmonton and get to take in the Red Wings / Oilers game tonight, so life is good.

In the paper this morning, I saw a story that made me think about errors and standardized work. We've been talking about human error recently with these two stories:

After the celebration, some of Crosby's valuable memorabilia, including the game-winning puck, went missing. Speculation ran rampant that somebody had stolen the stuff and it would never be seen again.

The most prized puck in Canadian history traversed the Atlantic Ocean in the pocket of a referee's shirt and spent more than two days in a sweat-soaked athletic bag before being discovered by a forgetful Finnish linesman.

It turns out there was no intent to steal the puck, or I assume that can be believed. The paper blames the linesman — he forgot… human error. Many workplace errors and medical errors come down to somebody forgetting. Can we design systems that make it hard to forget? I assume it's hard for a pilot to come in for a landing while forgetting to put the landing gear down (I assume there is a technological and/or process prevention in place).

It wasn't just that the one individual forgot (just like one firefighter wasn't the only one involved in parking a truck on railroad tracks) — the hockey federation people also forgot to come find the puck right after the game. The linesman did, as usual, and retrieved a goal scoring puck from the net… but then the puck remained in the pocket of the linesman's jersey and traveled all the way back to Finland in a gym bag.

From the story:

Because Mr. Crosby scored in overtime, ending the game instantly, organizers forgot to track the winning puck. That was the red-faced admission of the International Ice Hockey Federation on Tuesday.

Communications director Szymon Szemberg acknowledged gross errors in the post-game puck-retrieval process, admitting that the federation was guilty of “oversight and absent-mindedness” in a story posted on its website.

“In all the commotion and excitement that followed this defining goal, we simply lost our routine and – to a certain extent – our composure,” Mr. Szemberg said.

In a crazy set of circumstances, people lost their composure and forgot. That's one way human error occurs. I remember that exact same scenario from an episode of Grey's Anatomy (I blogged about it: “”McDreamy” Fights the Blame Game on “Grey's Anatomy”). In that episode, a doctor “forgot” to look down the throat of a woman who was rescued from a fire and the patient ended up dying — it was preventable had the doctor not forgotten (she would have seen soot and realized there was a risk of swelling). Part of the reason the doctor forgot was the unusually chaotic chaos of the E.D. that day (as opposed to normal chaos).

Lesson learned — we have to design systems that realize that we're human and prone to mistakes. We can't design systems that rely on highly skilled people being perfectly careful. My good friend Pete Abilla (blog, twitter) points out often that what we often call Toyota's “Respect for People” approach was originally called “Respect for Humanity.” That doesn't just mean, Pete says, that we should respect people… he says, based on his time at Toyota, that we should respect the humanity of people, including the fact that we're not perfect — including the “forgetful Finn.”

Are you taking measures in your workplace that reduce reliance on people always remembering? Are you taking measures to reduce chaos so that people aren't distracted, leading to errors??

In his book, Bob Lutz talks about forgetting to put down the landing gear of the MIG jet he had as his personal plane. One reporter asked him “so how did that feel?” Lutz said “not as bad as if I ran over my dog”. A couple of weeks later, Lutz ran over his dog (his dog recovered and forgave him). The point is that (most) people, particularly those who should know better do not do these things out of subconscious malice or stupidity.

That’s funny about Lutz. Those mistakes certainly don’t make him a dummy or a criminal! I have a lot of respect for Lutz and have been a big fan after seeing him give a talk during business school in the late 90’s (he was still with Chrysler, I think).